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CPAP for Severe OSA
March 3, 2019
snoring and sleep problems
You May Be At Risk of Obstructive Sleep Apnea
March 3, 2019
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As any school kid can tell you tests can be hard, and nerve-wracking, and the results are rarely humorous. But, making a joke about a test can diffuse some of the anxiety. “I got fired from my job at Pepsi because I tested positive for coke.” Or, never test how deep the water is with both feet.”, Or, “I failed my driver test because when I was asked what do you do at a red light, I said I usually respond to texts, read emails, and check Facebook.” Or even, “Math test: Bob has 36 candy bars. He ate 29. What does he have now? Answer. Diabetes.”

But, there really is nothing to worry about in getting tested for OSA. Testing is easy, and painless. And while it is true that fear of the results of any medical test, can make anyone lose sleep, a diagnosis of sleep apnea, will just put you on the way to recovery!

Getting an Appointment

Of course, you will see your doctor first for an evaluation that is based on our signs and symptoms, and any examination and/or test results you have. You would of course have a physical examination, where your doctor would examine the back of your throat mouth and nose for any signs of extra tissue. Your waist and neck circumferences may be measured. Your blood pressure will be checked.

Then he or she may refer you to a sleep specialist at a sleep center for further evaluation.

A Sleep Specialist

The sleep specialist can conduct additional tests to diagnose your conditions or determine how severe your condition is and a plan for any treatment. The testing here or evaluation can be an overnight monitoring of your breathing and other body functions while you sleep.

Polysomnography

This is a popular sleep study where you would be hooked up to monitors for your heart, lungs and brain activity, breathing patterns, any arm and leg movements, and blood oxygen levels, all while you sleep. It is a multiple component test that will electronically transmit and record certain physical activities while sleeping. This may be done in a sleep disorder center or sometimes at home with available portable equipment. The equipment you are hooked up to may look uncomfortable, but most people do fall asleep quite easily.

Surface electrodes are put on your face and head that record signals from your brain and muscle activity to the measuring equipment that records it digitally. Belts are also placed around chest and abdomen to measure breathing. An oximeter probe is put on a finger to measure the amount of oxygen in your blood.

If it is at an American Academy of Sleep Medicine (AASM) accredited sleep disorder center, which sets the standard for accredited sleep studies, the study will also include an EEG and chin electromyogram (EMG, ECG) for monitoring heart rhythm, an anterior tibialis EMG to record leg movements, thermal sensors and nasal pressure transducer to monitor airflow at the nose and mouth.

This study can be either a full night or a split night. In a split night, you would be monitored during the first half of the night, and then if you are diagnosed with obstructive sleep apnea, you make be woken and given a continuous positive airway pressure apparatus (CPAP) for the second half of the night. In either case, a qualified sleep specialist would review the results to determine whether or not you have sleep apnea or another type of sleep disorder. If you are diagnosed with OSA, and then receive a CPAP device the doctor can then adjust the positive airway pressure therapy if it is useful for you.

The polysomnography sleep study is also helpful to rule out other sleep problems such as restless leg syndrome or narcolepsy, both of which do cause daytime fatigue, but could need different treatment than OSA.

OSA-obstructive apnea is determined as the cessation of airflow for at least 10 seconds with continuous respiratory effort. Hypopnea is a 30% or more decrease in the flow of breathing lasting at least 10 seconds, and generally accompanied by a 4% or more oxyhemoglobin desaturation.

In other words, a 50% or more reduction in air flow lasting at least 10 seconds with either a 3% or more oxygen level in the blood decrease or an arousal is determined to be OSA.

The Multiple Sleep Latency Test (MSLP)

This test is devised to measure excessive daytime sleepiness and requires a sleep technician. It measures the time duration from the start of a daytime nap period to the first signs of sleep, which is called sleep latency. The test is based on the idea that the sleepier people are, the faster they will fall asleep.

The test consists of 4-5 naps of 15-20 minutes every 2 hours during the day. The time the start of latency to sleep for each nap is averaged to determine daytime sleep latency. The first nap is 1 1/2 hours to 3 hours after you wake up–often from an overnight sleep study. About an hour before your first nap you have a light breakfast. A sleep technologist places sensors on your head, face and chin which show when you are asleep and awake, and determine when you are in REM sleep. The readings measure how long it takes for you to fall asleep, and also how long it takes for you to reach REM sleep. If you can’t fall asleep that nap trail will end after 20 minutes, and you will have your two-hour break awake.

Normal daytime sleep latency is considered to be more than 10-15 minutes. Obstructive Sleep Apnea Hypopnea (OSAHS) is determined with a score of latencies of less than 10 minutes

The nap trial begins when the lights are turned off. You will lie quietly in bed and try to go to sleep. The MSLT will measure how long it takes you to fall asleep. It will also measure how long it takes for you to reach REM sleep.

At the end, the technologist will give the results over to the board-certified sleep medicine physician or your doctor to interpret.

The Berlin Sleep Questionnaire

The Berlin questionnaire contains 10 questions covering three categories including 1) snoring severity, 2) excessive daytime sleepiness, and 3) history of high blood pressure or obesity.

It requires a doctor or medical staff to analyze your responses. The responses need to be scored with an answer key so it is not often used by primary care offices.

High risk for obstructive sleep apnea is considered to be positive scores in at least 2 of the 3 categories.

Low risk for oSA is a positive score in only one or none of the categories.

You can print out the questionnaire from this link:

This is the questionnaire.

Height (m) ____ Weight (kg)_____ Age____ Male/Female

Please choose the correct response to each question.

CATEGORY 1

  1. Do you snore?
  2. Yes
  3. No
  4. Don‘t know

If you snore:

  1. Your snoring is:
  2. Slightly louder than breathing
  3. As loud as talking
  4. Louder than talking
  5. Very loud – can be heard in adjacent rooms
  6. How often do you snore
  7. Nearly every day
  8. 3-4 times a week
  9. 1-2 times a week
  10. 1-2 times a month
  11. Never or nearly never
  12. Has your snoring ever bothered other people?
  13. Yes
  14. No
  15. Don’t Know
  16. Has anyone noticed that you quit breathing during your sleep?
  17. Nearly every day
  18. 3-4 times a week
  19. 1-2 times a week
  20. 1-2 times a month
  21. Never or nearly never

CATEGORY 2

  1. How often do you feel tired or fatigued after your sleep?
  2. Nearly every day
  3. 3-4 times a week
  4. 1-2 times a week
  5. 1-2 times a month
  6. Never or nearly never
  7. During your waking time, do you feel tired, fatigued or not up to par?
  8. Nearly every day
  9. 3-4 times a week
  10. 1-2 times a week
  11. 1-2 times a month
  12. Never or nearly never
  13. Have you ever nodded off or fallen asleep while driving a vehicle?
  14. Yes
  15. No

If yes:

  1. How often does this occur?
  2. Nearly every day
  3. 3-4 times a week
  4. 1-2 times a week
  5. 1-2 times a month
  6. Never or nearly never

CATEGORY 3

  1. Do you have high blood pressure?

Yes

No

Don’t know

Categories and scoring:

Category 1: items 1, 2, 3, 4, 5.

Item 1: if ‘Yes’, assign 1 point

Item 2: if ‘c’ or ‘d’ is the response, assign 1 point

Item 3: if ‘a’ or‘b’ is the response, assign 1 point

Item 4: if ‘a’ is the response, assign 1 point

Item 5: if’ a’ or‘b’ is the response, assign 2 points

Add points. Category 1 is positive if the total

score is 2 or more points

Category 2: items 6, 7, 8 (item 9 should be noted

separately).

Item 6: if ‘a’ or‘b’ is the response, assign 1 point

Item 7: if ‘a’ or‘b’ is the response, assign 1 point

Item 8: if ‘a’ is the response, assign 1 point

Add points. Category 2 is positive if the total score is 2 or more points

Category 3 is positive if the answer to item 10 is ‘Yes’ OR if the BMI of the patient is greater than 30kg/m2

(BMI must be calculated. BMI is defined as weight (kg) divided by height (m) squared., kg/m2).

High Risk: if there are 2 or more Categories where the score is positive

Low Risk: if there is only 1 or no Categories where the score is positive

Oximetry

This is a test that monitors and records blood oxygen levels while sleeping. So, this test would likely show a drop-in blood oxygen level during any apneas you would have and then a rise in blood oxygen level with any brief awakenings from apneas. Usually, if this test reveals the drops in oxygen that signify OSA, a polysomnogram may follow to confirm a diagnosis of OSA.

Portable Monitoring

If you feel you could never sleep in a strange place like a sleep lab, you may be able to be tested in your own bed with a home version of polysomnography. It will measure airflow, breathing patterns and blood oxygen levels. Studies have revealed that at home approaches with home portable monitoring showed positive probability in diagnosing OSA. Studies also recommended a two-stage model for at home which is a screening questionnaire followed by home sleep monitoring. This was found to be accurate in identifying OSA.

Check-up With Ear, Nose and Throat Doctors

This may be advised by your doctor to rule out any anatomic blockages in your breathing passages.

EEG Electroencephalogram

This is used t measure and record brain wave activity.

EMG Electromyogram

This can record muscle activity such as face twitches, teeth grinding and leg movements and can also determine REM stages in sleeping.

EOG Eletrooculogram

This can be used to record eye movements which are important in determining different sleep stages especially REM stage of sleep.

ECG Electrocardiogram

This records heart rate and rhythm.

Nasal Airflow Sensor

This can record airflow.

Snore Microphone

This can record snoring activity.

Simple Self Diagnosis

The Snore Score from American Sleep Apnea Association

What’s Your Snore Score? Answer yes or no to each question.

  1. Are you a loud and/or regular snorer?
  2. Have you been observed to gasp or stop breathing during sleep?
  3. Do you feel tired or groggy upon awakening, or do you awaken with a headache?
  4. Are you often tired or fatigued during wake time hours?
  5. Do you fall asleep sitting, reading, watching TV or driving?
  6. Do you often have problems with memory or concentration?

The snore score results are:

One or more of these symptoms means you maybe be at a higher risk for having obstructive sleep apnea.

If you are also overweight, your neck circumference is large and/or have high blood pressure your risk of having obstructive sleep apnea is greater.

Epworth Sleepiness Scale

This is an at home questionnaire to determine your level of sleepiness by your rating how likely are you to doze off or fall asleep in usual situations, in contrast to feeling just tired. Even if you have not done some of these things recently put the best answer to how they would have affected you.

You can find it to print out on: http://www.narcolepsynetwork.org/wp-content/uploads/2010/05/ESS_Form-052210.pdf

Here is the test:

Use this scale to determine your level of sleepiness. You choose the best number from 0-3 for each situation. You should rate your chances of dozing off, not just feeling tired.

0 = no chance of dozing

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Situations:

Sitting and reading ____

Watching TV ____

Sitting inactive in a public place ____

As a passenger in a motor vehicle for an hour or

more ____

Lying down to rest in the afternoon when

circumstances permit ____

Sitting and talking to someone ____

Sitting quietly after lunch without alcohol ____

In a car, while stopped for a few minutes in

traffic ____

Total score (add the scores up)

(This is your Epworth score) _

This is how your score is interpreted:

0-7:It is unlikely that you are abnormally sleepy.

8-9:You have an average amount of daytime sleepiness.

10-15:You may be excessively sleepy depending on the situation. You may want to consider

seeking medical attention.

16-24:You are excessively sleepy and should consider seeking medical attention.

The S.T.O.P.-B.A.N.G. Questionnaire

The STOP-BANG questionnaire is an easy-to-use screening tool for patients with moderate to severe OSA, which can be used as a preoperative assessment tool. Less complex than the Berlin questionnaire it includes pertinent questions and other variables such as body mass index, age, neck size, and gender information. The stop bang questionnaire is eight easily answered questions that start with the acronym STOP-Bang. A score of equal to or greater than 3 shows high sensitivity for detecting OSA.

The acronym stands for Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference and Gender. These questions can help spot a person who has not been assessed in a formal sleep study.

The S.T.O.P.-B.A.N.G. can be printed out at this link:

This questionnaire has 8 questions to be answered with a yes or no. The questionnaire is:

Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? Yes No

Do you often feel TIRED, fatigued, or sleepy during daytime? Yes No

Has anyone OBSERVED you stop breathing during your sleep? Yes No

Do you have or are you being treated for high blood PRESSURE? Yes No

Do you have a BMI more than 35kg/m2? Yes No

Is your AGE over 50 years old? Yes No

Is your NECK circumference > 16 inches (40cm)? Yes No

Is your GENDER: Male? Yes No

In the stop bang model this rating has been determined for OSA:

If you answer Yes to 0-2 questions, -Low risk,

yes to 3-4 questions intermediate risk,

yes to 5-8 questions high risk.

Are You Present or Absent for Your Tests?

You know the joke about absence? It goes like this:

father; why did you get such a low score in the test?

Son: absence

Father You were absent on the day of the test?

Son: No, but the boy who sits next to me was.

The point is, don’t be absent or absentminded about going for a test, or testing yourself and seeing medical professionals. And don’t rely on someone sitting next to you either…you gotta do this one yourself.

Tips and Takeaways

  • If you think you may have sleep apnea, get tested!
  • There are a variety of tests available, from simple questionnaires, to complex sleep studies.
  • A diagnosis will likely lead to successful treatment options.

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